Guest Columnist

Doctors, Drugs and the Poor

By ATUL GAWANDE

Published: May 17, 2007

It’s one of those questions no one tells you about when you enter medical practice. What do you do when patients come who can’t pay? Some doctors decline to see them. I have expenses to pay and a family to feed, they’ll argue.

But I grew up in a rural part of Ohio where an inordinate number of poor people live. My mother is a pediatrician there, and from the start, she could not imagine turning children away. Up to 20 percent of her patients have been without insurance, and more than half were on Medicaid, which paid terribly and was refused by other doctors. Some patients were not very grateful. Some were not as poor as they claimed. But we could count on my father’s better-paying urology practice to cross-subsidize. So that’s what she did.

The message from my parents was straightforward: We are in medicine and that comes with certain moral obligations. So I’ve understood that part of my job is to see those who can’t pay — even if sometimes it hurts.

I’ve been thinking about this as I’ve watched the arguments unfold about what pharmaceutical companies should charge in the developing world. The history of H.I.V. drugs has not been pretty. First, for almost a decade, we in the West ignored the possibility that antiretroviral drugs could be used in the developing world. (Remember the 2001 claim of U.S. government officials that Africans couldn’t learn to take the drugs on time because they didn’t have watches?) Then, under international pressure, drug companies made some discounts, but they were not deep enough. (A year’s supply was still more than $1,000 per patient.) Only when an Indian generic manufacturer provided a copycat three-drug regimen for $150 per year and major donors stepped forward did distribution effectively reach poor countries.

We’re now in the throes of another round of H.I.V. drug battles, this time over advanced, but even more expensive drug regimens from Merck and Abbott Laboratories. Last week, the Clinton Foundation endorsed decisions by Thailand and Brazil to break the companies’ patents and purchase cheaper, copycat versions of the drugs. Abbott retaliated by withholding seven new drugs from Thailand, including an antibiotic, a painkiller, and a medication for high-blood pressure. The fight has become vicious.

In a way, it’s hard to see how the confrontation could be avoided. The cost of developing a new drug now approaches $1 billion, and companies do need profit margins to recoup that cost and encourage new innovation. Yet, once a life-saving discovery is made, it is clearly grotesque to make millions suffer or die while waiting for a 20-year patent to expire.

The experience with H.I.V. drugs is oddly heartening, though. There is, in fact, a spectrum of behavior among pharmaceutical companies — just like with doctors. Gilead Sciences has granted licenses to generic manufacturers to supply its blockbuster H.I.V. drug, Viread, to the world’s hundred poorest countries at the reasonable royalty rate of 5 percent of sales. Bristol-Meyers Squibb licensed its second-line drug, Reyataz, completely free of royalties to generic manufacturers for India and southern Africa. And through the World Health Organization’s bulk vaccine purchasing arrangements, manufacturers have been able to make significant profits selling vaccines at low cost but large volumes. This is the progress we want to build upon.

Pressure to broaden these efforts will grow, and it should. Agreement on regional pricing tiers and distribution networks for H.I.V. drugs show likelihood of solidifying in ways that make drugs available and support innovation, but we have nothing like it for drugs for heart disease, lung disease, or cancer. Meanwhile, the world is changing. The No. 1 cause of death in India, China, and Vietnam is not H.I.V. It’s heart disease. Cancer is in the top 10. Their people need clot-busting drugs, chemotherapies, and EKG machines just like everyone else. Manufacturers need to show the same willingness to make these life-saving technologies available to the poor.

Some will argue, hey, companies just invent this stuff; it isn’t their job to make sure every country gets some. But that’s not right. As Arthur Caplan, the bioethicist, points out, “You aren’t manufacturing pantyhose when you’re in health care. There are special moral duties attached.”

And one of them is: If you’re building a lifeboat, you have to think about how many you can get inside.

Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.

A version of this op-ed appeared in print on May 17, 2007, on page A25 of the New York edition with the headline: Doctors, Drugs And the Poor.